Conservation of blood is a priority during surgery, owing to shortages of donor blood and risks associated with transfusion of blood products.[9,10] However, blood transfusions have been linked to a number of negative postoperative sequelae, including poorer prognosis after cardiac and cancer surgery.[11- 21] In this context, recognition that allogeneic transfusion-associated immunomodulation can increase morbidity in allogeneically transfused patients has become a major concern in transfusion medicine.[9,22,23] In cancer surgery, various studies have documented a positive association between transfusion and death and relapse. In several retrospective analyses of transfusions in colorectal cancer surgery, long-term survival (3 to 5 years) ranged from 60% to 81% for patients not transfused vs 37% to 63% for transfused patients (for all studies, P < .05).[13-15] In one of these studies, the deleterious effect of transfusion was evident in some patients after they received a single unit of blood. In other studies, perioperative blood transfusion was identified as an independent risk factor for colorectal cancer relapse (P = .05).[13,15] Discrepant long-term and short-term survival rates have also been observed in patients with esophageal carcinoma, based on perioperative allogeneic-blood-transfusion status.[17,20] In most of the studies involving esophageal resection, intraoperative allogeneic blood transfusion was an independent predictor of, or prognostic covariate for, patient survival.[ 9,16,18,19,21,24] Reducing the Need for Allogeneic Blood Transfusion Bacterial infection, mistransfusion, and transfusion-related acute lung injury account for most transfusion-related deaths, with bacterial contamination responsible for approximately seven deaths per million units transfused. Although it is the third leading cause of transfusion-related mortality, transfusion-related acute lung injury has been frequently underdiagnosed and underreported, even when it occurred in several patients receiving transfusions from the same frequent plasma donor. Thus, transfusionrelated acute lung injury represents a substantial risk for patients receiving a transfusion. Evidence from animal models indicates that transfusion of platelet concentrates may cause transfusion- related acute lung injury as a result of infusion of bioactive lipids generated during storage. Not unexpectedly, the risk of transfusion- related infection in cardiopulmonary bypass patients depends on the number of units transfused. Multiple linear and logistic regression analyses of data from patients (n = 238) who underwent first-time coronary artery bypass graft surgery indicated that the amount of homologous blood transfused was a significant and independent predictor of postoperative infection. Infections were observed in 3.9% of patients receiving up to 2 units of red blood cells (RBCs) or whole blood, 6.9% of patients receiving 3 to 5 units, and 22% of patients receiving 6 units or more (P = .0022). Although the risk of transmission of infectious agents is well recognized, the dose-response relationship between transfusion and infection may also be attributed to the immunosuppressive effects of homologous blood transfusions. A dose-dependent rate of infection has been seen in other studies of transfused cardiopulmonary bypass populations.[ 27] Higher rates of postoperative bacterial infections occurred in patients transfused with packed cells without buffy coat compared with patients given leukocyte-depleted blood (P = .06 overall and P = .04 for those who received more than three transfusions). Mortality within 60 days was also significantly lower in patients receiving leukocyte-depleted blood (P = .025) compared with recipients of packed cells, and the effect was dose-dependent. Similarly, a recent retrospective cohort study in 23 Canadian hospitals found significantly lower unadjusted in-hospital mortality rates following the introduction of leukoreduction, compared with the control period (6.19% vs 7.03%, respectively; P = .04). Notably, the adjusted odds of death following leukoreduction were decreased (odds ratio [OR]: 0.87; 95% confidence interval [CI]: 0.75 to 0.99), but serious nosocomial infections did not decrease (adjusted OR: 0.97; 95% CI: 0.87 to 1.09) compared with the control period. Although leukocytes in transfused blood can produce immunomodulatory effects that increase the risk of infection, the significant reduction in mortality following leukoreduction cannot be fully explained by marginal changes in infection incidence noted in the previous studies. The precise mechanisms underlying the link between leukoreduction and outcome have not yet been elucidated, but it has been postulated that transfused leukocytes, activated during storage, contribute to an existing inflammatory response and exacerbate tissue damage. Recent studies indicate that not only are short-term mortality and morbidity increased by blood transfusion, but also long-term survival rates are reduced. A review of long-term patient- survival data (n = 1,915) from the United States Social Security Death Index showed that blood transfusion during or after coronary artery bypass graft surgery is associated with decreased long-term survival. In a separate study, transfused cardiopulmonary bypass patients had twice the 5-year mortality of nontransfused patients (15% vs 7%, respectively). After correction for comorbidities and other factors, transfusion was still associated with a 70% increase in mortality (relative risk [RR]: 1.7; 95% CI: 1.4 to 2.0; P = .001). Transfusion remained a significant predictor (P = .04) of long-term (1- to 5-year) mortality in multivariate analysis. Finally, reexploration for bleeding was identified as a strong independent risk factor for operative mortality (P = .005) in a separate multivariate logistic regression analysis of data from cardiopulmonary bypass patients (n = 6,015). Serine Proteases in Coagulation and Inflammation
Clearly, although the amount of perioperative bleeding in cancer surgery can be substantial enough in some cases to warrant a blood transfusion, such transfusions do have the potential to negatively impact patient outcomes by generating immunosuppressive and generalized inflammatory responses. It is interesting that hemostasis and inflammation share several reactants in common and both serve as hostdefense mechanisms.[2,30] The activation of coagulation and inflammation is closely linked through a network of both humoral and cellular components, including proteases of the coagulation and fibrinolytic cascade.[ 5] Serine proteases are essential for virtually all inflammatory and coagulative processes in the extracellular or plasma phase, and they are represented by such ubiquitous molecules as trypsin, thrombin, plasmin, plasminogen activator (PA), kallikrein, and elastase. The normal physiologic response to injury results in the generation of procoagulants, primarily tissue factor, which initiates thrombin generation and clot formation, and in the generation of plasminogen activator, which is central to coordinated cell proliferation and tissue remodeling. Generation of thrombin is key to activation and release of several humoral mediators involved in hemostasis and inflammation. A critical serine protease of the hemostatic system, thrombin is the final common mediator of both the intrinsic and extrinsic coagulation pathways, mediating the proteolytic cleavage of fibrinogen to fibrin and catalyzing the cross-linkage of the fibrin clot.[31-36] Clot formation is typically initiated by a series of platelet-related events that, together with blood trauma and/or the exposure of blood to tissue factor, promote activation of the coagulation system.[2,33-36] Amplification and progression of the hemostatic system requires the presence of an organizing surface, zymogen, cofactor, and serine protease.[ 2] Thrombin, in addition to being a major effector protease in the coagulation cascade (converting fibrinogen to fibrin), has many secondary effects.[ 31,32] For example, this serine protease triggers expression of procoagulant activity on the platelet surface by activating cofactors of tenase and prothrombinase complexes, supporting the generation of additional thrombin. Thrombin is a direct agonist of platelet activation and aggregation through a protease-activated-receptor- mediated series of events.[31,32] It triggers platelet release of platelet agonists such as adenosine diphosphate, serotonin, and thromboxane, which further amplify the platelet-activation process, and it triggers release of chemokines and growth factors.[2,37] In addition, thrombin mobilizes adhesive proteins and activates the platelet glycoprotein (GP) IIb/IIIa receptor, which has high affinity for fibrinogen and von Willebrand factor.[32,38-40] Thrombin is integral to angiogenesis and smooth-muscle-cell proliferation, by stimulating secretion of growth factors such as platelet-derived growth factor and vascular endothelial growth factor.[31,32,41-44] Thrombin activates inflammatory processes and is chemotactic for monocytes and mitogenic for lymphocytes.[ 5,32,41] Fibrinolysis and the PlasminogenPlasmin System
Once a fibrin surface is formed, fibrinolysis is initiated by the generation of plasmin, a serine protease with broad trypsin-like specificity.[1,4,45,46] Plasmin not only is responsible for the degradation of fibrin, fibrinogen, and other clotting factors during clot dissolution, but it also is capable of degrading virtually all components of the extracellular matrix (ECM). In addition, it stimulates activation of other proteases, such as MMPs and elastase, which further degrade the extracellular matrix. Plasmin is derived from its precursor plasminogen (zymogen) via the endogenous plasminogen activators urokinase-type PA (uPA) and tissuetype PA (tPA)[1,4,45-47] (Figure 1). These two enzymes appear to have different physiologic roles, with tPA being primarily associated with clot lysis and uPA mediating tissue-remodeling processes. Even small amounts of plasminogen activator can result in high local concentrations of plasmin, through the action of uPA and tPA. These activators are opposed by plasminogen-activator inhibitors (PAIs), designated PAI-1, -2, and -3, and the activity of plasmin itself is regulated by naturally occurring serine protease inhibitors, such as alpha2-antiplasmin and alpha2-macroglobulin. Urokinase-type plasminogen activator is secreted by a variety of both normal and neoplastic cells as a singlechain proenzyme (pro-uPA) with virtually no intrinsic enzymatic activity.[ 1,47] However, pro-uPA can be activated by a variety of serine proteases, including plasmin, kallikrein, and trypsin-like enzymes, producing a high-molecular-weight form of uPA that is further degraded into enzymatically active low-molecular-weight uPA. Indeed, trace amounts of plasmin are able to activate pro-uPA, thus generating a feedback mechanism of prou PA and plasminogen activation. The specific cellular receptor for uPA (uPA-R) is found on a variety of cell types and appears to play a central role in mediating pericellular proteolytic activity.[1,46-48] After secretion, pro-uPA binds to uPA-R and is activated by proteolytic cleavage to the enzymatically active uPA form. The interaction of uPA with uPA-R ensures focal localization of enzyme activity on the cell surface, and plasminogen activation is accelerated owing to the juxtaposition of uPA and plasminogen. In addition to maximizing uPA and plasminogen interactions, such binding also impedes inactivation by naturally occurring inhibitors. Thus, the cell surface is the preferential site for plasminogen activation as uPA binds to its specific cellular receptor. Bound uPA is more active than unbound uPA for plasmin generation. This arrangement is optimal for efficient generation of pericellular proteolytic activity.[1,47,48] Multifunctionality of Serine Protease Inhibitors
A single-chain polypeptide comprising 58 amino-acid residues, aprotinin inhibits the action of numerous serine proteases, with decreasing affinity for trypsin, plasmin, kallikrein, elastase, urokinase, and thrombin, respectively. The complex pharmacodynamics of aprotinin translates into a dose-dependent effect on serine protease activity. At low concentrations (eg, about 50 kallikrein-inhibiting units [KIU]/mL), aprotinin is a powerful inhibitor of plasmin, but at higher concentrations (> 200 KIU/mL) it also possesses inhibitory activity against kallikrein, elastase, urokinase, and thrombin (Figure 2). Hemostatic Properties of Aprotinin
Although the source of cardiopulmonary bypass-induced coagulopathy is multifactorial, platelet dysfunction has been implicated as a primary cause of postoperative bleeding in this setting.[ 8,50,51] During extracorporeal circulation of blood, the expression of platelet adhesive receptors, such as glycoprotein (GP) Ib, GP IIb, GP IIa, and GP IIb/IIIa, is reduced. This decline in the numbers of adhesion receptors on the platelet surface is mediated in part by plasmin.[52,53] Dysregulated fibrinolysis also contributes to the hemostatic defect that accompanies extracorporeal circulation.[ 50] During fibrinolysis, platelet receptors bind fibrin degradation products in place of fibrinogen, leading to impaired platelet aggregation and function. Aprotinin acts in a variety of interrelated ways to reduce platelet dysfunction by inhibiting serine proteases, such as plasmin and kallikrein, and preserving platelet receptors (eg, GP Ib and others).[8,51,54] Plasmin is directly inhibited by aprotinin, but aprotinin also blocks contact activation of kallikrein, which is partly responsible for creating enzymatically active uPA that converts plasminogen to plasmin. These antiplasmin activities retard the inhibitory effect of plasmin on the expression of platelet adhesive receptors. Furthermore, the inhibition of plasmin by aprotinin directly diminishes fibrinolysis, in turn causing a reduction in fibrin/fibrinogen degradation products, such as Ddimer, that otherwise would impair platelet function. Thus, the hemostatic effect of aprotinin can be attributed to both its inhibition of fibrinolytic activity and its preservation of platelet membrane-binding functions. Clinical studies have established that the antifibrinolytic and plateletprotective properties of aprotinin can decrease blood loss and transfusions in several subsets of surgical patients.[ 55-60] Subsequent double-blind, randomized, placebo-controlled studies confirmed the transfusion-sparing properties of aprotinin in primary and reoperative cardiac surgery.[57-60] Recent results from randomized, controlled studies have also shown that aprotinin decreases perioperative bleeding and blood-transfusion requirements in a dose-dependent fashion, in orthopedic and transplantation surgery as well as cancer surgery. A study in orthopedic surgery (n = 58), which compared "largedose" (4 106 KIU loading dose, followed by 1 * 106 KIU/h infusion) and "small-dose" aprotinin (2 * 106 KIU loading dose, followed by 5 * 105 KIU/ h infusion), showed a significant reduction (P < .05) in postoperative drainage in the two aprotinin groups, compared with placebo. Total measured bleeding and total calculated bleeding decreased significantly (both P < .05) in the large-dose group compared with placebo but did not achieve statistical significance in the smalldose group. The total number of transfused homologous and autologous units was also significantly decreased (P < .05) in the large-dose aprotinin group vs the placebo group. In orthotopic liver transplantation (European Multicentre Study in Aprotinin in Liver Transplantation), aprotinin significantly lowered intraoperative blood loss, with a reduction of 60% in the "high-dose" group and 44% in the "regular-dose" group compared with placebo (P = .03 comparing all three groups).[62,63] The "high-dose" aprotinin regimen consisted of a 2 * 106 KIU loading dose, followed by 1 * 106 KIU/h infusion, plus 1 * 106 KIU before graft reperfusion. The "regular-dose" group received a full Hammersmith regimen. A comparison of these dosing schedules showed that the total amount of homologous and autologous RBC transfusion requirements was 37% lower in "high-dose" recipients and 20% lower in "regular-dose" recipients, compared with patients in the placebo group (P = .02, comparing all three groups). These findings are in line with the significant reduction (P < .03) in transfusion requirements with aprotinin reported in the reoperative heart-transplantation study. Thus, aprotinin has been shown to improve hemostasis in both cardiac and abdominal surgery. Studies in Cancer Patients Importantly, significant blood- and transfusion-sparing effects have also been demonstrated with aprotinin in patients undergoing resection for primary malignant, metastatic, or benign tumors of the liver.[64,65] In a doubleblind, prospective, randomized study, patients (n = 97) undergoing elective liver resection were stratified by diagnosis and assigned to "large-dose" aprotinin (2 * 106 KIU loading dose, followed by 5 * 105 KIU/h infusion, plus a 5 * 105 KIU bolus for every 3 transfused RBC units) or placebo. Results showed a significant overall reduction in intraoperative blood loss with aprotinin, compared with placebo (mean: 1,217 vs 1,653 mL, respectively; P = .048). In stepwise logistic regression analysis, aprotinin treatment remained significantly correlated with blood loss after an adjustment for diagnosis of underlying disease, age, preoperative hematocrit, type of surgery, duration of clamping, repeat surgery, and postoperative Ddimer levels. The percentage of transfused patients (17% vs 39%, respectively; P = .02) and the total transfusion requirement (30 vs 77 RBC units, respectively; P = .015) were also significantly lower in the aprotinin group vs the placebo group. Given the independent prognostic value of PAI-1 levels in at least some tumor types,[66,67] it is noteworthy also that the increase in PAI levels in this study was significantly lower with aprotinin than with placebo (P < .0001). The overall findings of the previous study were reproduced in a subanalysis restricted to patients with colorectal metastasis. In this cohort, intraoperative blood loss (P = .037) and transfusion requirements (P = .03) were significantly reduced in patients treated with aprotinin vs placebo. A similar intraoperative increase in thrombin-antithrombin complexes in aprotinin and placebo groups indicated a comparable activation of coagulation. As in the whole study population, however, aprotinin significantly reduced (P = .01) intraoperative hyperfibrinolysis compared with placebo, as measured by intergroup comparison of D-dimer levels. Most of the safety experience with aprotinin has been outside the oncology setting, in patients undergoing cardiac surgery. Current evidence indicates that clinically relevant doses of aprotinin not only are generally safe and well tolerated,[58,59,68- 71] but also are associated with lower mortality risk in this patient population.[ 71] When considered together, ample evidence indicates that blood transfusions increase the risk of mortality and relapse, and may, in fact, be an independent risk factor for these events following resection of some tumors. The underlying mechanisms for these adverse outcomes have yet to be fully elucidated but may include transfusion- related immunosuppression and inflammation. Immune suppression not only increases the risk of postoperative infections but probably also increases the odds of cancer relapse and recurrence. These immune-system changes take place in a milieu of transfusion-induced inflammation and resulting tissue injury. Accordingly, use of serine protease inhibitors or other transfusion-sparing agents may contribute to improved outcomes after resection of intrathoracic and intra- abdominal malignant disease.
The author(s) have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
1. Mignatti P, Rifkin DB: Biology and biochemistry of proteinases in tumor invasion. Physiol Rev 73:161-195, 1993.
2. Royston D: Serine protease inhibition prevents both cellular and humoral responses to cardiopulmonary bypass. J Cardiovasc Pharmacol 27(Suppl 1):S42-S49, 1996.
3. Peters DC, Noble S: Aprotinin: An update of its pharmacology and therapeutic use in open heart surgery and coronary artery bypass surgery. Drugs 57:233-260, 1999.
4. Dunbar SD, Ornstein DL, Zacharski LR: Cancer treatment with inhibitors of urokinasetype plasminogen activator and plasmin. Expert Opin Investig Drugs 9:2085-2092, 2000.
5. Levy JH, Tanaka KA: Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg 75:S715-S720, 2003.
6. Royston D: Aprotinin versus lysine analogues: The debate continues. Ann Thorac Surg 65(4 Suppl):S9-S19; discussion S27-S28, 1998.
7. Hill GE, Alonso A, Spurzem JR, et al: Aprotinin and methylprednisolone equally blunt cardiopulmonary bypass-induced inflammation in humans. J Thorac Cardiovasc Surg 110:1658-1662, 1995.
8. Mojcik CF, Levy JH: Aprotinin and the systemic inflammatory response after cardiopulmonary bypass. Ann Thorac Surg 71:745-754, 2001.
9. Vamvakas EC, Blajchman MA: Deleterious clinical effects of transfusionassociated immunomodulation: Fact or fiction? Blood 97:1180-1195, 2001.
10. Advisory Committee on Blood Safety and Availability: Prioritizing Decisions in Transfusion Medicine: Transfusion Transmissible Diseases. HHS 2002:1-217. Available at: http://www.hhs.gov/bloodsafety/ transcripts/20030123.html. Accessed June 3, 2003.
11. Murphy PJ, Connery C, Hicks GL Jr, et al: Homologous blood transfusion as a risk factor for postoperative infection after coronary artery bypass graft operations. J Thorac Cardiovasc Surg 104:1092-1099, 1992.
12. Engoren MC, Habib RH, Zacharias A, et al: Effect of blood transfusion on long-term survival after cardiac operation. Ann Thorac Surg 74:1180-1186, 2002.
13. Leite JF, Granjo ME, Martins MI, et al: Effect of perioperative blood transfusions on survival of patients after radical surgery for colorectal cancer. Int J Colorectal Dis 8:129- 133, 1993.
14. Houbiers JG, Brand A, van de Watering LM, et al: Randomised controlled trial comparing transfusion of leucocyte-depleted or buffy-coat-depleted blood in surgery for colorectal cancer. Lancet 344:573-578, 1994.
15. Chiarugi M, Buccianti P, Disarli M, et al: Effect of blood transfusions on disease-free interval after rectal cancer surgery. Hepatogastroenterology 47:1002-1005, 2000.
16. Dresner SM, Lamb PJ, Shenfine J, et al: Prognostic significance of peri-operative blood transfusion following radical resection for oesophageal carcinoma. Eur J Surg Oncol 26(5):492-497, 2000.
17. Gertsch P, Vauthey JN, Lustenberger AA, et al: Long-term results of transhiatal esophagectomy for esophageal carcinoma. A multivariate analysis of prognostic factors. Cancer 72:2312-2319, 1993.
18. Christein JD, Hollinger EF, Millikan KW: Prognostic factors associated with resectable carcinoma of the esophagus. Am Surg 68:258-262; discussion 262-263, 2002.
19. Langley SM, Alexiou C, Bailey DH, et al: The influence of perioperative blood transfusion on survival after esophageal resection for carcinoma. Ann Thorac Surg 73:1704-1709, 2002.
20. Craig SR, Adam DJ, Yap PL, et al: Effect of blood transfusion on survival after esophagogastrectomy for carcinoma. Ann Thorac Surg 66:356-361, 1998.
21. Nozoe T, Miyazaki M, Saeki H, et al: Significance of allogenic blood transfusion on decreased survival in patients with esophageal carcinoma. Cancer 92:1913-1918, 2001.
22. Lapierre V, Auperin A, Tiberghien P: Transfusion-induced immunomodulation following cancer surgery: fact or fiction? J Natl Cancer Inst 90:573-580, 1998.
23. Pereira A: Deleterious consequences of allogenic blood transfusion on postoperative infection: Really a transfusion-related immunomodulation effect? Blood 98:498-500, 2001.
24. Motoyama S, Saito R, Kamata S, et al: Survival advantage of using autologous blood transfusion during surgery for esophageal cancer. Surg Today 32:951-958, 2002.
25. Kopko PM, Marshall CS, MacKenzie MR, et al: Transfusion-related acute lung injury. Report of a clinical look-back investigation. JAMA 287:1968-1971, 2002.
26. Silliman CC, Bjornsen AJ, Wyman TH, et al: Plasma and lipids from stored platelets cause acute lung injury in an animal model. Transfusion 43:633-640, 2003.
27. van de Watering LM, Hermans J, Houbiers JG, et al: Beneficial effects of leukocyte depletion of transfused blood on postoperative complications in patients undergoing cardiac surgery: A randomized clinical trial. Circulation 97:562-568, 1998.
28. Hebert PC, Fergusson D, Blajchman MA, et al; Leukoreduction Study Investigators. Clinical outcomes following institution of the Canadian universal leukoreduction program for red blood cell transfusions. JAMA 289:1941- 1949, 2003.
29. Moulton MJ, Creswell LL, Mackey ME, et al: Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations. J Thorac Cardiovasc Surg 111:1037-1046, 1996.
30. Zacharski LR: Anticoagulants in cancer treatment: malignancy as a solid phase fibrinolysis activation in malignancy. Semin Thromb Hemost 18:104-116, 1992.
31. Fritz H, Wunderer G: Biochemistry and applications of aprotinin, the kallikrein inhibitor from bovine organs (article in German). Arzneimittelforschung 33:479-494, 1983.
32. Prend/ergast TW, Furukawa S, Beyer AJ 3rd, et al: Defining the role of aprotinin in heart transplantation. Ann Thorac Surg 62:670-674, 1996.
33. Bates SM, Weitz JI: Prevention of activation of blood coagulation during acute coronary ischemic syndromes: Beyond aspirin and heparin. Cardiovasc Res 41:418-432, 1999.
34. Westaby S: Aprotinin in perspective. Ann Thorac Surg 55:1033-1041, 1993.
35. Weber C, Springer TA: Neutrophil accumulation on activated, surface-adherent platelets in flow is mediated by interaction of Mac-1 with fibrinogen bound to alphaIIbbeta3 and stimulated by platelet-activating factor. J Clin Invest 100:2085-2093, 1997.
36. Adelman B, Michelson AD, Loscalzo J, et al: Plasmin effect on platelet glycoprotein Ib-von Willebrand factor interactions. Blood 65(1):32-40, 1985.
37. van Oeveren W, Harder MP, Roozendaal KJ, et al: Aprotinin protects platelets against the initial effect of cardiopulmonary bypass. J Thorac Cardiovasc Surg 99:788-796; discussion 796-797, 1990.
38. Murkin JM, Lux J, Shannon NA, et al: Aprotinin significantly decreases bleeding and transfusion requirements in patients receiving aspirin and undergoing cardiac operations. J Thorac Cardiovasc Surg 107:554-561, 1994. 56. Royston D, Bidstrup BP, Taylor KM, et al: Effect of aprotinin on need for blood transfusion after repeat open-heart surgery. Lancet 2:1289-1291, 1987.
39. Lemmer JH Jr, Dilling EW, Morton JR, et al: Aprotinin for primary coronary artery bypass grafting: A multicenter trial of three dose regimens. Ann Thorac Surg 62:1659- 1667; discussion 1667-1668, 1996.
40. Cosgrove DM 3rd, Heric B, Lytle BW, et al: Aprotinin therapy for reoperative myocardial revascularization: A placebocontrolled study. Ann Thorac Surg 54:1031- 1036; discussion 1036-1038, 1992.
41. Levy JH, Pifarre R, Schaff HV, et al: A multicenter, double-blind, placebo-controlled trial of aprotinin for reducing blood loss and the requirement for donor-blood transfusion in patients undergoing repeat coronary artery bypass grafting. Circulation 92:2236-2244, 1995.
42. Alderman EL, Levy JH, Rich JB, Nili M, et al: Analyses of coronary graft patency after aprotinin use: results from the International Multicenter Aprotinin Graft Patency Experience (IMAGE) trial. J Thorac Cardiovasc Surg 116:716-730, 1998.
43. Samama CM, Langeron O, Rosencher N, et al: Aprotinin versus placebo in major orthopedic surgery: A randomized, doubleblinded, dose-ranging study. Anesth Analg 95:287-293, 2002.
44. Porte RJ, Molenaar IQ, Begliomini B, et al: Aprotinin and transfusion requirements in orthotopic liver transplantation: A multicentre randomised double-blind study. EMSALT Study Group. Lancet 355:1303- 1309, 2000.
45. Porte RJ, Molenaar IQ, Begliomini B, et al for the EMSALT Study Group. Aprotinin reduces blood loss and transfusion requirements in orthotopic liver transplantation: A placebo-controlled multicenter study [Abstract 1015]. Abstract presented at: 18th Annual Scientific Meeting of the American Society of Transplantation; May 15-19, 1999; Chicago, Ill.
46. Lentschener C, Benhamou D, Mercier FJ, et al: Aprotinin reduces blood loss in patients undergoing elective liver resection. Anesth Analg 84:875-881, 1997.
47. Lentschener C, Li H, Franco D, et al: Intraoperatively-administered aprotinin and survival after elective liver resection for colorectal cancer metastasis. A preliminary study. Fibrinol Proteol 13:39-45, 1999.
48. Grondahl-Hansen J, Peters HA, van Putten WL, et al: Prognostic significance of the receptor for urokinase plasminogen activator in breast cancer. Clin Cancer Res 1:1079-1087, 1995.
49. Harbeck N, Dettmar P, Thomssen C, et al: Prognostic impact of tumor biological factors on survival in node-negative breast cancer. Anticancer Res (3C):2187-2197, 1998.
50. Lemmer JH Jr, Stanford W, Bonney SL, et al: Aprotinin for coronary artery bypass grafting: Effect on postoperative renal function. Ann Thorac Surg 59:132-136, 1995.
51. Lemmer JH Jr, Stanford W, Bonney SL, et al: Aprotinin for coronary bypass operations: Efficacy, safety, and influence on early saphenous vein graft patency. A multicenter, randomized, double-blind, placebo-controlled study. J Thorac Cardiovasc Surg 107:543-551; discussion 551-553, 1994.
52. Smith PK, Muhlbaier LH: Aprotinin safe and effective only with the full-dose regimen. Ann Thorac Surg 62(6):1575-1577, 1996.
53. Levi M, Cromheecke ME, de Jonge E, et al: Pharmacological strategies to decrease excessive blood loss in cardiac surgery: A metaanalysis of clinically relevant endpoints. Lancet 354:1940-1947, 1999.
54. Marcus AJ: Thrombosis and inflammation as multicellular processes: Significance of cell-cell interactions. Semin Hematol 31:261-269, 1994.
55. Cicala C, Cirino G: Linkage between inflammation and coagulation: An update on the molecular basis of the crosstalk. Life Sci 62:1817-1824, 1998.
56. Esmon CT: Role of coagulation inhibitors in inflammation. Thromb Haemost 86:51-56, 2001.
57. Libby P, Simon DI: Inflammation and thrombosis: The clot thickens. Circulation 103(13):1718-1720, 2001.
58. Bernard A, Deschamps C, Allen MS, et al: Pneumonectomy for malignant disease: Factors affecting early morbidity and mortality. J Thorac Cardiovasc Surg 121:1076-1082, 2001.
59. Ruffini E, Parola A, Papalia E, et al: Frequency and mortality of acute lung injury and acute respiratory distress syndrome after pulmonary resection for bronchogenic carcinoma. Eur J Cardiothorac Surg 20(1):30- 36, discussion 36-37, 2001.
60. Kutlu CA, Williams EA, Evans TW, et al: Acute lung injury and acute respiratory distress syndrome after pulmonary resection. Ann Thorac Surg 69:376-380, 2000.
61. Stephan F, Boucheseiche S, Hollande J, et al: Pulmonary complications following lung resection: A comprehensive analysis of incidence and possible risk factors. Chest 118:1263-1270, 2000.
62. Avendano CE, Flume PA, Silvestri GA, et al: Pulmonary complications after esophagectomy. Ann Thorac Surg 73:922-926, 2002.
63. Vaporciyan AA, Merriman KW, Ece F, et al: Incidence of major pulmonary morbidity after pneumonectomy: Association with timing of smoking cessation. Ann Thorac Surg 73:420- 425; discussion 425-426, 2002.
64. Murkin JM: Cardiopulmonary bypass and the inflammatory response: A role for serine protease inhibitors? J Cardiothorac Vasc Anesth 11(2 Suppl 1):19-23; discussion 24-25, 1997.
65. Donahue MA, Price PM: Aprotinin: Antifibrinolytic and antiinflammatory mechanisms of action in cardiac surgery with cardiopulmonary bypass. Dynamics 13:16-23, 2002.
66. Parolari A, Alamanni F, Antona C, et al: Heart surgery, cardiopulmonary bypass and inflammatory response. I. Changes in hemostasis and complement [in Italian]. G Ital Cardiol 26:431-446, 1996.
67. Hill GE, Whitten CW, Landers DF: The influence of cardiopulmonary bypass on cytokines and cell-cell communication. J Cardiothorac Vasc Anesth 11:367-375, 1997.
68. Miller BE, Levy JH: The inflammatory response to cardiopulmonary bypass. J Cardiothorac Vasc Anesth 11:355-366, 1997.
69. Clermont G, Vergely C, de Girard C, et al: Cellular injury associated with extracorporeal circulation [in French]. Ann Cardiol Angeiol (Paris) 51:38-43, 2002.
70. Casey LC: Role of cytokines in the pathogenesis of cardiopulmonary-induced multisystem organ failure. Ann Thorac Surg 56(5 Suppl):S92-S96, 1993.
71. Wachtfogel YT, Kucich U, Hack CE, et al: Aprotinin inhibits the contact, neutrophil, and platelet activation systems during simulated extracorporeal perfusion. J Thorac Cardiovasc Surg 106:1-9; discussion 9-10, 1993.
72. Himmelfarb J, Holbrook D, McMonagle E: Effects of aprotinin on complement and granulocyte activation during ex vivo hemodialysis. Am J Kidney Dis 24:901-906, 1994.
73. Poullis M, Manning R, Laffan M, et al: The antithrombotic effect of aprotinin: Actions mediated via the protease-activated receptor 1. J Thorac Cardiovasc Surg 120:370-378, 2000.
74. Mossinger H, Dietrich W, Braun SL, et al: High-dose aprotinin reduces activation of hemostasis, allogeneic blood requirement, and duration of postoperative ventilation in pediatric cardiac surgery. Ann Thorac Surg 75:430-437, 2003.
75. Englberger L, Kipfer B, Berdat PA, et al: Aprotinin in coronary operation with cardiopulmonary bypass: Does “low-dose” aprotinin inhibit the inflammatory response? Ann Thorac Surg 73:1897-1904, 2002.
76. Wei M, Kuukasjarv P, Laurikka J, et al: Cardioprotective effect of pump prime aprotinin in coronary artery bypass grafting. Cardiovasc Drugs Ther 16:37-42, 2002.
77. Tweddell JS, Berger S, Frommelt PC, al: Aprotinin improves outcome of singleventricle palliation. Ann Thorac Surg 62:1329- 1335; discussion 1335-1336, 1996.
78. Rahman A, Ustunda B, Burma O, et al: Does aprotinin reduce lung reperfusion damage after cardiopulmonary bypass? Eur J Cardiothorac Surg 18:583-588, 2000.
79. Goldberg GI, Frisch SM, He C, et al: Secreted proteases. Regulation of their activity and their possible role in metastasis. Ann N Y Acad Sci 580:375-384, 1990.
80. Ornstein DL, Zacharski LR: Cancer, thrombosis, and anticoagulants. Curr Opin Pulm Med 6:301-308, 2000.
81. Prandoni P, Lensing AW, Cogo A, et al: The long-term clinical course of acute deep venous thrombosis. Ann Intern Med 125:1-7, 1996.
82. Johnson MJ, Walker ID, Sproule MW, et al: Abnormal coagulation and deep venous thrombosis in patients with advanced cancer. Clin Lab Haematol 21:51-54, 1999.
83. Zacharski LR, Ornstein DL, Gabazza EC, et al: Treatment of malignancy by activation of the plasminogen system. Semin Thromb Hemost 28:5-18, 2002.
84. Edwards RL, Rickles FR, Moritz TE, et al: Abnormalities of blood coagulation tests in patients with cancer. Am J Clin Pathol 88:596-602, 1987.
85. Ito R, Statland BE: Selected hemostatic abnormalities associated with neoplastic disease. Clin Lab Med 2:599-625, 1982.
86. Bromberg ME, Cappello M: Cancer and blood coagulation: Molecular aspects. Cancer J Sci Am 5:132-138, 1999.
87. Falanga A, Rickles FR: Pathophysiology of the thrombophilic state in the cancer patient. Semin Thromb Hemost 25:173- 182, 1999.
88. Gropp C, Egbring R, Havemann K: Fibrinogen split products, antiproteases and granulocytic elastase in patients with lung cancer. Eur J Cancer 16:679-685, 1980.
89. Gilead Z, Zahavi R, Hatzubai A, et al: Levels of fibrinogen/fibrin degradation fragment E and related substances in sera and effusions of patients with malignant disease. J Cancer Res Clin Oncol 106:195-201, 1983.
90. Walenga JM, Hoppensteadt D, Emanuele RM, et al: Performance characteristics of a simple radioimmunoassay for fibrinopeptide A. Semin Thromb Hemost 10:219-227, 1984.
91. Mombelli G, Monotti R, Haeberli A, et al: Relationship between fibrinopeptide A and fibrinogen/fibrin fragment E in thromboembolism, DIC and various nonthromboembolic diseases. Thromb Haemost 58:758-763, 1987.
92. Kohli M, Fink LM, Spencer HJ, et al: Advanced prostate cancer activates coagulation: A controlled study of activation markers of coagulation in ambulatory patients with localized and advanced prostate cancer. Blood Coagul Fibrinolysis 13:1-5, 2002.
93. Ornstein DL, Zacharski LR: Treatment of cancer with anticoagulants: Rationale in the treatment of melanoma. Int J Hematol 73:157- 161, 2001.
94. Walz DA, Fenton JW: The role of thrombin in tumor cell metastasis. Invasion Metastasis. 14:303-308, 1994-95.
95. Zacharski LR, Memoli VA, Morain WD, et al: Cellular localization of enzymatically active thrombin in intact human tissues by hirudin binding. Thromb Haemost 73:793-797, 1995.
96. Wojtukiewicz MZ, Zacharski LR, Memoli VA, et al: Malignant melanoma. Interaction with coagulation and fibrinolysis pathways in situ. Am J Clin Pathol 93:516-521, 1990.
97. Thornes RD, Daly L, Lynch G, et al: Treatment with coumarin to prevent or delay recurrence of malignant melanoma. J Cancer Res Clin Oncol 120(Suppl):S32-S34, 1994.
98. Chahinian AP, Propert KJ, Ware JH, et al: A randomized trial of anticoagulation with warfarin and of alternating chemotherapy in extensive small-cell lung cancer by the Cancer and Leukemia Group B. J Clin Oncol 7:993- 1002, 1989.
99. Lebeau B, Chastang C, Brechot JM, et al: Subcutaneous heparin treatment increases survival in small cell lung cancer. “Petites Cellules” Group. Cancer 74:38-45, 1994.
100. Milroy R, Douglas JT, Campbell J, et al: Abnormal haemostasis in small cell lung cancer. Thorax 43:978-981, 1988.
101. Meehan KR, Zacharski LR, Moritz TE, et al: Pretreatment fibrinogen levels are associated with response to chemotherapy in patients with small cell carcinoma of the lung: Department of Veterans Affairs Cooperative Study 188. Am J Hematol 49:143-148, 1995.
102. Daly L: The first international urokinase/warfarin trial in colorectal cancer. Clin Exp Metastasis 9:3-11, 1991.
103. Levine M, Hirsh J, Gent M, et al: Double-blind randomised trial of a very-lowdose warfarin for prevention of thromboembolism in stage IV breast cancer. Lancet 343:886-889, 1994.
104. Cosgrove RH, Zacharski LR, Racine E, et al: Improved cancer mortality with lowmolecular- weight heparin treatment: A review of the evidence. Semin Thromb Hemost 28:79- 87, 2002.
105. Duffy MJ, Maguire TM, McDermott EW, et al: Urokinase plasminogen activator: A prognostic marker in multiple types of cancer. J Surg Oncol 71:130-135, 1999.
106. Look MP, van Putten WL, Duffy MJ, et al: Pooled analysis of prognostic impact of urokinase-type plasminogen activator and its inhibitor PAI-1 in 8377 breast cancer patients. J Natl Cancer Inst 94:116-128, 2002.
107. Duffy MJ, O’Grady P, Devaney D, et al: Urokinase-plasminogen activator, a marker for aggressive breast carcinomas. Preliminary report. Cancer 62:531-533, 1988.
108. Janicke F, Schmitt M, Ulm K, et al: Urokinase-type plasminogen activator antigen and early relapse in breast cancer. Lancet 2:1049, 1989.
109. Duffy MJ, Reilly D, McDermott E, et al: Urokinase plasminogen activator as a prognostic marker in different subgroups of patients with breast cancer. Cancer 74:2276- 2280, 1994.
110. Foekens JA, Schmitt M, van Putten WL, et al: Prognostic value of urokinase-type plasminogen activator in 671 primary breast cancer patients. Cancer Res 52:6101-6105, 1992.
111. Ossowski L, Aguirre Ghiso J, Liu D, et al: The role of plasminogen activator receptor in cancer invasion and dormancy. Medicina (Buenos Aires) 59(5 Pt 2):547-552, 1999.
112. Fidler IJ: Critical factors in the biology of human cancer metastasis: Twenty-eighth G.H.A. Clowes memorial award lecture. Cancer Res 50:6130-6138, 1990.
113. Chambers AF, Groom AC, MacDonald IC: Dissemination and growth of cancer cells in metastatic sites. Nat Rev Cancer 2:563-572, 2002.
114. He CS, Wilhelm SM, Pentland AP, et al: Tissue cooperation in a proteolytic cascade activating human interstitial collagenase. Proc Natl Acad Sci U S A 86:2632-2636, 1989.
115. Chambers AF, Matrisian LM: Changing views of the role of matrix metalloproteinases in metastasis. J Natl Cancer Inst 89(17):1260- 1270, 1997.
116. Liu G, Shuman MA, Cohen RL: Coexpression of urokinase, urokinase receptor and PAI-1 is necessary for optimum invasiveness of cultured lung cancer cells. Int J Cancer 60:501-506, 1995.
117. Stein-Werblowsky R: On the prevention of haematogenous tumor metastases in rats. The role of the proteinase inhibitor “Trasylol.” J Cancer Res Clin Oncol 97:129-135, 1980.
118. Stein-Werblowsky R: On the prevention of haematogenous tumour metastasis to liver and lung. Experientia 36:108-109, 1980.
119. Uetsuji S, Yamamura M, Takai S, et al: Effect of aprotinin on metastasis of Lewis lung tumor in mice. Surg Today 22:439-442, 1992.
120. Turner GA, Weiss L: Analysis of aprotinin-induced enhancement of metastasis of Lewis lung tumors in mice. Cancer Res 41:2576-2580, 1981.
121. Monden T, Morimoto H, Shimano T, et al: Use of fibrinogen to enhance the antitumor effect of OK-432. A new approach to immunotherapy for colorectal carcinoma. Cancer 69:636-642, 1992.
122. Zimbler N, Wall CN, Townsend ER, et al: Use of intra-operative high dose aprotinin may be associated with improved longer term outcome following esophagectomy for cancer. [Abstract A-1187] Abstract presented at the American Society of Anesthesiologists Annual Meeting. Orlando, FL; Oct 14-16, 2002.
123. Amar D, Grant EM, Zhang H, et al: Antifibrinolytic therapy and perioperative blood loss in cancer patients undergoing major orthopedic surgery. Anesthesiology. 98:337- 342, 2003.
124. Jeserschek R, Clar H, Aigner C, et al: Reduction of blood loss using high-dose aprotinin in major orthopaedic surgery: A prospective, double-blind, randomised and placebo-controlled study. J Bone Joint Surg Br 85:174-177, 2003.
125. Homeister JW, Satoh P, Lucchesi BR: Effects of complement activation in the isolated heart. Role of the terminal complement components. Circ Res 71(2):303-319, 1992.
126. MacNee W, Selby C: New perspectives on basic mechanisms in lung disease. 2. Neutrophil traffic in the lungs: Role of haemodynamics, cell adhesion, and deformability. Thorax 48:79-88, 1993.
127. Frenette PS, Wagner DD: Adhesion molecules—Part II: Blood vessels and blood cells. N Engl J Med 335:43-45, 1996.
128. Wakelin MW, Sanz MJ, Dewar A, et al: An anti-platelet-endothelial cell adhesion molecule-1 antibody inhibits leukocyte extravasation from mesenteric microvessels in vivo by blocking the passage through the basement membrane. J Exp Med 184:229-239, 1996.
129. Bianchi E, Bender JR, Blasi F, et al: Through and beyond the wall: Late steps in leukocyte transendothelial migration. Immunol Today 18:586-591, 1997.
130. Kim KU, Kwon OJ, Jue DM: Protumour necrosis factor cleavage enzyme in macrophage membrane/particulate. Immunology 80:134-139, 1993.
131. Asehnoune K, Dehoux M, Lecon-Malas V, et al: Differential effects of aprotinin and tranexamic acid on endotoxin desensitization of blood cells induced by circulation through an isolated extracorporeal circuit. J Cardiothorac Vasc Anesth 16:447-451, 2002.
132. Asimakopoulos G, Lidington EA, Mason J, et al: Effect of aprotinin on endothelial cell activation. J Thorac Cardiovasc Surg 122:123-128, 2001.
133. Asimakopoulos G, Thompson R, Nourshargh S, et al: An antiinflammatory property of aprotinin detected at the level of leukocyte extravasation. J Thorac Cardiovasc Surg 120:361-369, 2000.
134. Pruefer D, Makowski J, Dahm M, et al: Aprotinin inhibits leukocyte-endothelial cell interactions after hemorrhage and reperfusion. Ann Thorac Surg 75:210-215; discussion 215- 216, 2003.
135. Liu B, Belboul A, Al-Khaja N: Effect of high-dose aprotinin on blood cell filterability associated with CPB. Coron Artery Dis 3:129- 132, 1992.
136. Eren S, Esme H, Balci AE, et al: The effect of aprotinin on ischemia-reperfusion injury in an in situ normothermic ischemic lung model. Eur J Cardiothorac Surg 23:60-65, 2003.
137. Uetsuji S, Yamamura M, Takai S, et al: Effect of aprotinin on metastasis of Lewis lung tumor in mice. Surg Today 22:439-442, 1992.
138. Turner GA, Weiss L: Analysis of aprotinin-induced enhancement of metastasis of Lewis lung tumors in mice. Cancer Res 41:2576-2580, 1981.
139. Monden T, Morimoto H, Shimano T, et al: Use of fibrinogen to enhance the antitumor effect of OK-432. A new approach to immunotherapy for colorectal carcinoma. Cancer 69:636-642, 1992.
140. Zimbler N, Wall CN, Townsend ER, et al: Use of intra-operative high dose aprotinin may be associated with improved longer term outcome following esophagectomy for cancer. [Abstract A-1187] Abstract presented at the American Society of Anesthesiologists Annual Meeting. Orlando, FL; Oct 14-16, 2002.
141. Amar D, Grant EM, Zhang H, et al: Antifibrinolytic therapy and perioperative blood loss in cancer patients undergoing major orthopedic surgery. Anesthesiology. 98:337- 342, 2003.
142. Jeserschek R, Clar H, Aigner C, et al: Reduction of blood loss using high-dose aprotinin in major orthopaedic surgery: A prospective, double-blind, randomised and placebo-controlled study. J Bone Joint Surg Br 85:174-177, 2003.
143. Homeister JW, Satoh P, Lucchesi BR: Effects of complement activation in the isolated heart. Role of the terminal complement components. Circ Res 71(2):303-319, 1992.
144. MacNee W, Selby C: New perspectives on basic mechanisms in lung disease. 2. Neutrophil traffic in the lungs: Role of haemodynamics, cell adhesion, and deformability. Thorax 48:79-88, 1993.
145. Frenette PS, Wagner DD: Adhesion molecules-Part II: Blood vessels and blood cells. N Engl J Med 335:43-45, 1996.
146. Wakelin MW, Sanz MJ, Dewar A, et al: An anti-platelet-endothelial cell adhesion molecule-1 antibody inhibits leukocyte extravasation from mesenteric microvessels in vivo by blocking the passage through the basement membrane. J Exp Med 184:229-239, 1996.
147. Bianchi E, Bender JR, Blasi F, et al: Through and beyond the wall: Late steps in leukocyte transendothelial migration. Immunol Today 18:586-591, 1997.
148. Kim KU, Kwon OJ, Jue DM: Protumour necrosis factor cleavage enzyme in macrophage membrane/particulate. Immunology 80:134-139, 1993.
149. Asehnoune K, Dehoux M, Lecon-Malas V, et al: Differential effects of aprotinin and tranexamic acid on endotoxin desensitization of blood cells induced by circulation through an isolated extracorporeal circuit. J Cardiothorac Vasc Anesth 16:447-451, 2002.
150. Asimakopoulos G, Lidington EA, Mason J, et al: Effect of aprotinin on endothelial cell activation. J Thorac Cardiovasc Surg 122:123-128, 2001.
151. Asimakopoulos G, Thompson R, Nourshargh S, et al: An antiinflammatory property of aprotinin detected at the level of leukocyte extravasation. J Thorac Cardiovasc Surg 120:361-369, 2000.
152. Pruefer D, Makowski J, Dahm M, et al: Aprotinin inhibits leukocyte-endothelial cell interactions after hemorrhage and reperfusion. Ann Thorac Surg 75:210-215; discussion 215- 216, 2003.
153. Liu B, Belboul A, Al-Khaja N: Effect of high-dose aprotinin on blood cell filterability associated with CPB. Coron Artery Dis 3:129- 132, 1992.
154. Eren S, Esme H, Balci AE, et al: The effect of aprotinin on ischemia-reperfusion injury in an in situ normothermic ischemic lung model. Eur J Cardiothorac Surg 23:60-65, 2003.